Provider Demographics
NPI:1447208004
Name:SERC OF HARRISONVILLE LLC
Entity type:Organization
Organization Name:SERC OF HARRISONVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:PURVIS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:816-380-3344
Mailing Address - Street 1:815 WESTCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:HARRISONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64701-1784
Mailing Address - Country:US
Mailing Address - Phone:816-380-3344
Mailing Address - Fax:816-380-3044
Practice Address - Street 1:815 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701-1784
Practice Address - Country:US
Practice Address - Phone:816-380-3344
Practice Address - Fax:816-380-3044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO02259225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO37003017OtherBCBS
MOW110000Medicare PIN